Viewpoints: Annoyances are Unavoidable; Frustration Isn't

When my daughter recently received her PhD
in psychology from Rice University, I was
particularly happy as an alumnus. Sitting
through the beautiful Saturday morning commencement,
I reflected about what undergraduate
courses were pertinent to clinical neurology. Most
were not specifically useful although the love of
learning and critical analysis are invaluable.
Curiously, the one subject I took at the last minute
for two semesters—Spanish (I speak it poorly)—is
the one that I often use. The typing skill I learned
from a junior high school class is something I use all
day long.

The commencement speaker, New York Times
columnist David Brooks, spoke about happiness. I
was thinking about our professional happiness.
Although most of us are very happy as neurologists,
we have become increasingly unhappy with the practice
of medicine due to issues large and small ranging
from decreasing reimbursement to loss of autonomy
to bothersome patient behaviors.

We performed a survey of Texas neurologists on
bothersome patient behaviors (Evans RW, Evans RE,
Evans RI. A survey of neurologists on bothersome
patient behaviors. Medscape General Medicine
8(4):35-43, 2006; available at
http://www.medscape.com/viewarticle/546878_4) and
found that the top five bothersome behaviors were:
no show for appointment; verbally abusive with your
staff; poor compliance with medications or treatment;
late for appointment; and do not know the medications
they are taking.

We're not the only ones, of course, subject to bothersome
behaviors of others. A new book by Palca
and Lichtman, Annoying: the Science of What Bugs
Us, discusses bothersome or annoying behaviors of
strangers, friends, and spouses, such as uncouth
habits, inconsiderate acts, intrusive behaviors, and
norm violations. Consider the following public behaviors:
cell phone conversations, crying babies, or someone
picking their nose or clipping their fingernails.
How irritating is someone kicking your chair in a
movie or car alarms that don't stop or a buzzing fly?

More research should be devoted to what bugs
physicians and detracts from the care of our patients.
This would almost certainly include precertification
forms for medications (consider one insurer only
allows FDA on-label use, while another wants you to
use a generic for off-label use), imaging pre-certs,
meaningful use requirements for EHRs (which are certain to grow and have questionable meaningful
use), and increasingly complicated coding. Many
things are more complicated without clear benefit.
Does the maze of recertification improve patient care?

There are trends in healthcare that physicians cannot
easily counter but which require more work by
physicians or addition of staff. Payors want to save
money and seem to set up human speed bumps.
Federal agencies want to analyze our behavior with
EHRs. Shouldn't we be compensated for our time for
all of these increasing mandates? More importantly,
will there be any time left for the physician and
patient?

Neurologists may not have much power to change
the mandates of Payors or the Federal government,
but there are steps we can take to address other
annoyances of daily practice. First and foremost, neurologists
should recognize and attend to their own
needs for personal time to deal or reduce stress and
support their own good health and well-being.

Randolph W. Evans, MD is Clinical Professor of
Neurology Baylor College of Medicine in Houston.

Adapted from an article first published in Broca's Area,
the newsletter of the Texas Neurological Society, Summer
2011.

Minimize Frustration

Ahead are a few additional suggestions for taking control of frequently-encountered challenges in the clinical setting. If you have strategies to
share with your colleagues, let us know.

Focus on quality and stress reduction. Although the culture of the practice setting overall was not found to significantly impact physician stress
or burnout, an organizational emphasis on quality led to fewer medical errors, a recent study found.1 The same study showed that stressed and
burned out physicians were more likely to make errors. Taking some time to de-stress in whatever manner is effective for the individual may be
good for clinicians—and their patients.

Confront burnout; Be proactive. It's better for surgeons to avoid burnout before it sets in, researchers discovered, rather than try to reverse it.2
The same seems to hold true for all healthcare providers. Confronting stress is essential. As the authors state, “Silence on career distress, as a
strategy, simply does not work among professionals whose careers, well-being, and level of patient care may be in jeopardy.”

Consider that frustration with patients may say something about you. While some patients are clearly difficult to deal with (see below), frequent
frustration may indicate high stress on the part of the physician.3 Analysis of data from a survey of various physicians found that, in addition to
a greater number of patients with psychosocial problems or substance abuse, “factors independently associated with high frustration included
age < 40 years, work hours > 55 per week, higher stress, practice in a medicine subspecialty.”

Adopt strategies for “difficult patient” behaviors. Empathy can be a useful tool in dealing with difficult patients. Patients who seem angry, irritated,
emotional, or otherwise challenging often move past their challenging reactions when the physician responds with validation, agreement,
or even just a few minutes of time for the patient.4 Abbott provides an overview of physician responses in a recent edition of Topics in
Stroke Rehabilitation4 or you may wish to read Hull, et al's piece in Family Practice Management.5

Know your rights regarding difficult patients. Faced with a difficult patient, a physician has the right to terminate the physician/patient relationship.
Importantly, the physician must do so in an appropriate manner to avoid charges of patient abandonment.6 This is not as cumbersome as it
may seem. Guidelines are available from the AMA (http://www.ama-assn.org/ama/pub/physician-resources/legal-topics/patient-physicianrelationship-
topics.page), and it is wise to verify state law as well.